You are here

Lady Montagu and the Introduction of Smallpox Inoculation to England

The English aristocrat and writer Lady Mary Wortley Montagu (1689-1762) is today remembered particularly for her letters from Turkey, an early example of a secular work by a Western woman about the Muslim Orient. When Lady Mary was in the Ottoman Empire, she discovered the local practice of variolation, the inoculation against smallpox. Unlike Jenner's later vaccination, which used cowpox, variolation used a small measure of smallpox itself. Lady Mary, who had suffered from the disease, encouraged her own children to be inoculated while in Turkey. On her return to London, she enthusiastically promoted the procedure, but encountered a great deal of resistance. However, her example certainly popularized the practice of inoculation with smallpox in British high society. The numbers inoculated remained small, and medical effort throughout the 18th century was concentrated on reducing the risks and side-effects of the inoculation process.

For a long time, smallpox was greatly feared, as one in three of those who contracted the disease died, and those who survived were often badly disfigured. Lady Mary Wortley Montagu discovered the Ottoman Empire concept of variolation during her stay in Istanbul in 1716-1718, and brought the idea back to Britain. A few years later, Voltaire, the French philosopher, recorded that 60% of people caught smallpox, with 20% of the population dying of it. In the years following 1770, several doctors in England and Germany had successfully tested the possibility of using the cowpox vaccine as an immunization for smallpox in humans.[1]

For centuries, smallpox was a terrible disease caused by the variola virus. It enters the body through the lungs and is carried in the blood to the internal organs, which it infects. The virus then spreads to the skin where it multiplies, causing a rash. Smallpox is characterised by fever, headache, backache and vomiting twelve days after exposure to the virus. The rash appears three days later, beginning as small discrete pink spots which grow bigger and become slightly raised. By the third day, there are tense blisters, 6 mm in diameter and deep in the skin. These eventually shrink, dry up and fall off, leaving a sunken scar. In severe cases, patients die of blood poisoning, secondary infections or internal bleeding. There is no effective treatment once infection has taken place.

Smallpox is a very ancient disease. The scars on the mummified body of the Pharaoh Ramses V, who died in the 12th century BCE, are believed to have been caused by smallpox. It spread throughout Europe and was carried to the Americas with the voyages of discovery, where it ravaged the Aztecs and North American Indians. Smallpox touched every section of society, killing kings, queens and emperors as well as the common man. Elizabeth I, Mozart, George Washington and Abraham Lincoln all experienced its terror. Those who survived the disease were often left scarred for life. This led to the fashions among ladies of wearing beauty spots or veils to hide their blemishes.

Smallpox - "the most dreadful scourge of the human species" according to Edward Jenner - was declared to be eradicated in 1980 after it had existed for thousands of years as a contagious and potentially fatal disease. The English doctor Edward Jenner (1749 – 1823) is credited with discovering the smallpox vaccine. Yet, as with all great breakthroughs, it could not have happened had he not been standing on the shoulders of others who did their bit to reduce the dangerous impact of this illness.

Before Dr. Jenner's discovery, the usual method of immunisation against smallpox was variolation, which is the earliest known inoculation technique and had been practiced for millennia throughout the world. Variolation involved exposing a healthy person to infected material in the hopes of inducing a mild form of the disease that provided immunity from further infection.

By the end of the 18th century, inoculation for smallpox was an established practice in several European countries. Some decades earlier, Doctor Timoni noted the method as he had observed it in Constantinople.[2] Other European doctors in Constantinople and a Reverend in America also raised awareness of the variolation process during this same period. However, the person acknowledged with promoting variolation in England in early 18th century is Lady Mary Wortley Montagu.

Long before vaccination for smallpox was developed in Europe in the 1790s, people in Asia, the Middle East, the Caucasus and Africa knew that small amounts of live smallpox virus injected under the skin would induce a mild form of the disease that rendered a person immune from full-blown smallpox. Several personalities in the early 18th-century England and America who knew about this procedure called variolation believed passionately in it.

Before the introduction of a vaccine, the mortality of the severe form of smallpox—variola major—was very high. Historical records show that a method of inducing immunity was already known. A process called inoculation, also known as insufflation or variolation, was practiced in India as early as 1000 BCE.[3] But this information is disputed. Other investigators contend the ancient Sanskrit medical texts of India do not describe these techniques.[4] The first clear reference to smallpox inoculation was made by the Chinese author Wan Quan (1499-1582) in his Douzhen xinfa published in 1549.[5] Inoculation for smallpox does not appear to have been widespread in China until the reign of the Emperor Longqing from the Ming Dynasty in the second half of the 16th century.[6]

Variolation was also practiced throughout the latter half of the 17th century in Turkey, Persia, and Africa. In 1714 and 1716, two reports of the Turkish method of inoculation were made to the Royal Society in England, by Emmanuel Timoni, a doctor affiliated to the British Embassy in Istanbul,[7] and Giacomo Pylarini. Lady Mary Wortley Montagu, wife of the British ambassador, is widely credited with introducing the process to Great Britain in 1721. The procedure had been performed on her son and daughter, aged 5 and 4 respectively. They both recovered quickly.

In 1721, an epidemic of smallpox hit London.[8] News of Lady Wortley Montagu's efforts made some patients eager to use inoculation on themselves. But doctors thought that it was a dangerous procedure, and the inoculation was tried progressively on several people, including condemned prisoners. The doctors inoculated the prisoners and all of them recovered in a couple of weeks. This outstanding result reassured on the safety of the treatment and the British royal family was inoculated.

Variolation was first employed in North America in 1721. The practice had been known in Boston since 1706, when Cotton Mather discovered that his slave Onesimus had been inoculated while still in Africa and that many slaves imported to Boston had also received inoculations.[9] The practice was, at first, widely criticized.[10] However a limited trial showed that 6 deaths occurred out of 244 who were vaccinated, while 844 out of 5980 died of natural disease, and the process was widely adopted throughout the colonies.[11] By 1777, George Washington, who initially hesitated to have his troops inoculated during a smallpox outbreak, eventually ordered mandatory inoculation of all troops and recruits who had not had the disease.[12]

Dr. Peter Kennedy, who was doing research in Constantinople, documented in his Essay on External Remedies published in London in 1715 that those who practice this method in Turkey: "scarred the wrists, legs, and forehead of the patient, placed a fresh and kindly pock in each incision and bound it there for eight or ten days, after this time the patient was credibly informed. The patient would then develop a mild case [of smallpox], recover, and thereafter be immune."[13]

Lady Mary was born in London either in April or May of 1689; she died also in London in 21 August 1762. She was the daughter of Evelyn Pierrepont, fifth Earl of Kingston-upon-Hull. Family holdings were extensive, including Thoresby Hall and Holme Pierrepont in Nottinghamshire, and a house in West Dean in Wiltshire. Thoresby Hall had one of the finest private libraries in England, but the library was lost when Thoresby Hall burned in 1744.[14]

Lady Mary's close friendships included Mary Astell, a champion of women's rights, and Anne Wortley Montagu, with both of whom she carried on an animated correspondence. Lady Mary was to marry Anne's brother, Edward Wortley Montagu. Lady Mary's father, now Marquess of Dorchester, rejected Wortley Montagu as a son-in-law because he refused to entail his estate on a possible heir. Negotiations were broken off, and when Lord Dorchester insisted on another marriage for his daughter, Edward and Mary eloped in 1712. The early years of Lady Mary Wortley Montagu's married life were spent in seclusion in the country. Her husband became Member of Parliament for Westminster in 1715, and shortly afterwards was made a Lord Commissioner of the Treasury. When Lady Mary joined him in London, her wit and beauty soon made her a prominent figure at court.

Early in 1716, Edward Wortley Montagu was appointed Ambassador at Istanbul. Lady Mary accompanied him to Vienna, and thence to Adrianople and Istanbul. He was recalled in 1717, but they remained at Istanbul until 1718. The story of this voyage and of her observations of Eastern life is told in the Turkish Embassy Letters, a series of lively letters full of graphic description. The book of the Letters is often credited as being an inspiration for subsequent female traveller/writers, as well as for much Orientalist art. Lady Mary returned to the West with knowledge of the Ottoman practice of inoculation against smallpox, known as variolation. Several decades later, in the 1790s, Edward Jenner developed the method of vaccination, based on the same principle.

Although her correspondence was published in the 19th century, scholarly editions of her works only appeared during the late 20th century (see the bibliography below). Several authors of travel accounts, history and of early encounters between East and West count her as a brilliant writer in these fields and credit her for her acute observation of the Ottoman life and customs, which were objective and well equilibrated.[15]

Lady Montagu was renowned as a writer and her works are used by scholars in many disciplines for their comments on politics, diplomacy, music, health, art, medical history and social history. In 2003, Jennifer Lee Carrell published The Speckled Monster: A Historical Tale of Battling Smallpox, which recounts the tale of Lady Mary's struggle to bring inoculation to London, drawing heavily on her diaries and personal correspondence.[16]

Figure 5: Portrait of Edward Anthony Jenner (1749-1823) the English scientist who is widely credited as the pioneer of smallpox vaccine.(Source)

When Lady Mary was in the Ottoman Empire, she discovered the local practice of inoculation against smallpox called variolation. Unlike Jenner's later vaccination, which used cowpox, variolation used a small measure of smallpox itself. Lady Mary's own brother had died of the disease, and she had herself suffered from the disease, prior to her visit to Turkey.[17] She was eager to spare her children similar suffering, and had them inoculated. On her return to London, she enthusiastically promoted the procedure, but encountered a great deal of resistance from the medical establishment both because it was an "Oriental" process and because of her gender.[18]

During her first year of living in the Ottoman Empire, Lady Montagu came across variolation (which she named ingrafting). She wrote to her friend Miss Sarah Chiswell (who died of smallpox 9 years later) and explained the process as she had seen it in Constantinople.

The procedure of "ingrafting" was done by old women, who made four or five scratches or a slight puncture on the arm and introduced material taken from smallpox pustules from patients who had mild cases of the disease. Lady Montagu was so determined to prevent the ravages of smallpox and so impressed by the Turkish method that she ordered the Embassy surgeon, Charles Maitland, to inoculate her 5-year-old son in March 1718. On returning to London in April 1721, she had Maitland inoculate her 4-year-old daughter in the presence of the physicians of the court. Among these physicians was Sir Hans Sloane, President of the Royal Society and the king's physician. This was the first professional variolation performed in England.[19]

Lady Montagu was so convinced of the efficacy of variolation in preventing the disease that she urged for trials of the variolation method. Consequently, word of her efforts spread and reached the Princess of Wales and other members of the Royal Family. Charles Maitland was granted royal license to perform a trial of variolation on six prisoners at Newgate on 9 August 1721; these prisoners were promised a full pardon if they submitted to the so-called Royal Experiment. The trial was observed by the court physicians and 25 members of the Royal Society and the College of Physicians. All of the prisoners survived and were released. One was exposed to two children with the illness and proved to be immune. Maitland later variolated six charity children in London and successfully treated the two daughters of the Princess of Wales on 17 April 1722. Not surprisingly, the procedure gained general acceptance after this last success.[20]

However, despite these first successes, there was still a risk of fatality since variolation could potentially spread the disease as inoculated people were temporarily carriers of smallpox. But for at least another seventy years, variolation was used as a form of immunisation against smallpox until Edward Jenner introduced his vaccine which involved the inoculation of humans with cowpox in order to prevent smallpox infection. (Incidentally, the term vaccine comes from the Latin word vacca, meaning cow).

Figure 6: Caricature by the English artist James Gillray (1757-1815) The Cow-Pock or the Wonderful Effects of the New Inoculation! (London, 1802) depicting a vaccination scene at the Smallpox and Inoculation Hospital at St. Pancras, showing Dr. Jenner vaccinating a frightened young woman and cows emerging from different parts of people's bodies. (Source)

On 14 May 1796, Jenner tested his theory by inoculating James Phipps, a young boy of 8 years, with material from the cowpox blisters of the hand of Sarah Nelmes, a milkmaid who had caught cowpox from a cow called Blossom,[21] whose hide hangs on the wall of the library at St George's medical school (now in Tooting). Blossom's hide commemorates one of the school's most renowned alumni. Phipps was the 17th case described in Jenner's first paper on vaccination.

Jenner inoculated Phipps with cowpox pus in both arms on the same day. The inoculation was accomplished by scraping the pus from Nelmes' blisters onto a piece of wood then transferring this to Phipps' arms. This produced a fever and some malaise but no serious illness. Later, he injected Phipps with variolous material, which would have been the routine method to produce immunity at that time. No disease followed. Jenner reported that later the boy was again challenged with variolous material and again showed no sign of infection.

Edward Jenner was himself variolated whilst at school. He was "prepared" by being starved, purged and bled; then locked up in a stable with other artificially infected boys until the disease had run its course. He suffered particularly badly. It was an experience he would never forget.

In more recent times, it is estimated that 300 million people died from smallpox during the 20th century. Following mass vaccination programmes after 1966, the World Health Organisation announced, fourteen years later, that the world is free of small pox.

In 1717 Lady Montagu arrived with her husband, the British ambassador, at the court of the Ottoman Empire. While living in Istanbul, she noted that the local practice of deliberately stimulating a mild form of the disease through inoculation conferred immunity. An account of the variolation is described by Lady Mary Wortley Montagu in a letter to Sarah Chiswell, dated 1 April 1717:

Figure 7: On January 1, 1967, the World Health Organisation began the Intensive Smallpox Eradication Program, one of the greatest triumphs in the history of medicine. The WHO employed a strategy of mass vaccination coupled with subsequent surveillance and containment. The disease was declared eradicated and large-scale vaccination ended worldwide in 1980. (Source)

"A propos of distempers, I am going to tell you a thing, that will make you wish yourself here. The small-pox, so fatal, and so general amongst us, is here entirely harmless, by the invention of engrafting, which is the term they give it. There is a set of old women, who make it their business to perform the operation, every autumn, in the month of September, when the great heat is abated. People send to one another to know if any of their family has a mind to have the small-pox; they make parties for this purpose, and when they are met (commonly fifteen or sixteen together) the old woman comes with a nut-shell full of the matter of the best sort of small-pox, and asks what vein you please to have opened. She immediately rips open that you offer to her, with a large needle (which gives you no more pain than a common scratch) and puts into the vein as much matter as can lie upon the head of her needle , and after that, binds up the little wound with a hollow bit of shell, and in this manner opens four or five veins.

The Grecians have commonly the superstition of opening one in the middle of the forehead, one in each arm, and one on the breast, to mark the sign of the Cross; but this has a very ill effect, all these wounds leaving little scars, and is not done by those that are not superstitious, who choose to have them in the legs, or that part of the arm that is concealed. The children or young patients play together all the rest of the day, and are in perfect health to the eighth. Then the fever begins to seize them, and they keep their beds two days, very seldom three. They have very rarely above twenty or thirty in their faces, which never mark, and in eight days time they are as well as before their illness. Where they are wounded, there remains running sores during the distemper, which I don't doubt is a great relief to it. Every year, thousands undergo this operation, and the French Ambassador says pleasantly, that they take the small-pox here by way of diversion, as they take the waters in other countries. There is no example of any one that has died in it, and you may believe I am well satisfied of the safety of this experiment, since I intend to try it on my dear little son. I am patriot enough to take the pains to bring this useful invention into fashion in England, and I should not fail to write to some of our doctors very particularly about it, if I knew any one of them that I thought had virtue enough to destroy such a considerable branch of their revenue, for the good of mankind. But that distemper is too beneficial to them, not to expose to all their resentment, the hardy wight that should undertake to put an end to it. Perhaps if I live to return, I may, however, have courage to war with them."[22]

[Wortley Montagu, Mary], Letters … Written during her Travels in Europe, Asia, and Africa to Persons of Distinction, Men of Letters, &c. … which Contain … Accounts of the Policy & Manners of the Turks. Berlin: Sold by August Mylius, 1781.

[1.] See Peter C. Plett, "Peter Plett und die übrigen Entdecker der Kuhpockenimpfung vor Edward Jenner"[Peter Plett and other discoverers of cowpox vaccination before Edward Jenner], Sudhoffs Archiv (Steiner, Stuttgart ), vol. 90, n° 2, 2006, pp. 219-32. In this article, detailed attention is given to the works of the German teacher Peter Plett (1766-1823), who had reported his findings about immunisation for smallpox in humans to the Medical Faculty of the University of Kiel, who disregarded them.[2.]E. Timoni, "An account, or history, of the procuring of the smallpox by incision or inoculation, as it has for some time been practised at Constantinople", Philosophical Transactions of the Royal Society, 1714-1716, vol. 29: pp. 72-82.[3.] K. Bourzac, "Smallpox: Historical Review of a Potential Bioterrorist Tool". Journal of Young Investigators vol. 6 (3), 2002.[4.] D. Wujastyk, "Medicine in India", in Oriental Medicine: An Illustrated Guide to the Asian Arts of Healing, London: Serindia Publications, 1995, pp.19-38.[5.] J. Needham, Science and Civilization in China, vol. 6: Biology and Biological Technology, Part 6: "Medicine", Cambridge: Cambridge University Press, 1999, pp.134 ff.[6.] In China, powdered smallpox scabs were blown up the noses of the healthy. The patients would then develop a mild case of the disease and from then on were immune to it. The technique did have a 0.5-2% mortality rate, but that was considerably less than the 20-30% mortality rate of the disease itself. See R. Temple, The Genius of China: 3000 Years of Science, Discovery, and Invention, New York: Simon and Schuster, 1986, p.137.[7.] A. M. Behbehani, The Smallpox Story: Life and Death of an Old Disease, Microbiological Reviews, vol. 47, n° 4, December 1983, pp. 455–509 (PDF).[8.] Ibid. See also M. M. Thein, L. G. Goh and K. H. Phua, "The Smallpox Story: From Variolation to Victory", Asia-Pacific Journal of Public Health, vol. 2, n° 3, 1988, pp. 203-10.[9.] Brian Willoughby, Black History Month II: Why Wasn't I Taught That?, published in Tolerance in the News (12 February 2004); reproduced here. (Retrieved 7.02.2010).[10.]The Boston Smallpox Epidemic, 1721, in Contagion: Historical Views of Diseases and Epidemics, The Harvard University Library, The Open Collections Program, 2008. (Retrieved 7.02.2010).[11.] Frank Fenner, "Smallpox and Its Eradication", History of International Public Health, No. 6, Geneva: World Health Organization, 1988.[12.]"George Washington to Major General Horatio Gates, 5–6 February 1777", in F. E. Grizzard et al., The Papers of George Washington, Charlottesville: University Press of Virginia, 1985, vol. 8.[13.] Peter Kennedy, An Essay on External Remedies Wherein it is Considered, Whether all the curable Distempers incident to Human Bodies, may not be cured by Outward Means. London: A. Bell, 1715.[14.] Details of her life are in Isobel Grundy, Lady Mary Wortley Montagu, Oxford University Press, 1999, p. 5 ff. See the review of the book by Sarah Prescott, Review of English Studies, New Series, vol. 51, No. 202, May 2000, pp. 300-303. See also [Wikipedia], Lady Mary Wortley Montagu (retrieved 6.02.2009).[15.] In Post Captain, which is the second volume of the popular Aubrey–Maturin series of historical novels written by Patrick O'Brian (published in 1972 in UK by Collins Publishers and in USA by Lippincott), Mrs Williams refers to Lady Montagu as a great traveler.[16.] Jennifer Lee Carrell, The Speckled Monster: A Historical Tale of Battling Smallpox, Penguin Plume, 2003, hardcover. Reviewed by John S. Marr, Medscape General Medicine, vol. 6(2), 2004, p. 44 (published online 10 May 2004: click here).[17.]R. Halsband, The Life of Lady Mary Wortley Montague, Oxford: Clarendon Press, 1956.[18.] Mary Wortley Montagu, Letters of the Right Honourable Lady M--y W---y M----e :written, during her travels in Europe, Asia and Africa, to persons of distinction, men of letters, &c. in different parts of Europe: which contain, among other curious relations, accounts of the policy and manners of the Turks: drawn from sources that have been inaccessible to other travellers (London: Printed for T. Becket and P. A. De Hondt ..., 1763); Letter XXXI [pp. 57-63, sequence 261-267). (Retrieved 7.02.2010).[19.] G. Miller, The Adoption of Inoculation for Smallpox in England and France, Philadelphia: University of Pennsylvania Press, 1957; R. P.Stearns, "Remarks upon the introduction of inoculation for smallpox in England", Bulletin for the History of Medicine, 1950, vol. 24, 1950, pp. 103-22; Charles Maitland, Mr. Maitland's account of inoculating the small pox, London: J. Downing, 1722 (digital edition by Harvard University Library, Page Delivery Service).[20.]W. Woodville,The History of the Inoculation of the Smallpox in Great Britain, London: J Phillips; 1796. For a summary, see See: Nicolau Barquet and Pere Domingo, Smallpox: The Triumph over the Most Terrible of the Ministers of Death, Annals of Internal Medicine, vol. 127, no. 8, Part 1, 15 October 1997, pp. 635-642.[21.]Smallpox, The Edward Jenner Museum (retrieved 6.02.2010).[22.] Letter from Lady Mary Wortley Montagu, in Letters of the Right Honourable Lady M--y W--y M--e: Written During her Travels in Europe, Asia and Africa…, vol. 1 (Aix: Anthony Henricy, 1796), pp. 167-69; letter 36, to Mrs. S. C. from Adrianople, n.d.; quoted in Paul Halsall, Internet Modern History Sourcebook [a collection of public domain and copy-permitted texts for introductory level classes in modern European and World history], July 1998. Quoted also in Lady Mary Wortley Montagu, Selected Turkish Embassy Letters, excerpts from The Letters and Works of Lady Mary Wortley Montagu, vol. 1, ed. by Lord Wharncliffe and W. Moy Thomas, London: Henry G. Bohn, 1861. (Retrieved 7.02.2010).

*The original article was produced by Salah Zaimeche, Salim Al-Hassani and Ahmed Salem. The members of the new FSTC Research Team have re-edited and revised this new version. The team now comprises of Mohammed Abattouy, Salim Al-Hassani, Mohammed El-Gomati, Salim Ayduz, Savas Konur, Cem Nizamoglu, Anne-Maria Brennan, Maurice Coles, Ian Fenn, Amar Nazir and Margaret Morris.